Improve Child Health Outcomes Research Articles

A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience Model

ObjectiveWe propose a transformative approach to foster collaboration across child health, public health, and community-based agencies to address the root causes of toxic stress and childhood adversity and to build community resilience. MethodsPhysicians, members of social service agencies, and experts in toxic stress and adverse childhood experiences (ACEs) were interviewed to inform development of the Building Community Resilience (BCR) model. Through a series of key informant interviews and focus groups, we sought to understand the role of BCR for child health systems and their partners to reduce toxic stress and build community resilience to improve child health outcomes. ResultsKey informants indicated the intentional approach to ACEs and toxic stress through continuous quality improvement (data-driven decisions and program development, partners testing and adapting to changes to their needs, and iterative development and testing) which provides a mechanism by which social determinants or a population health approach could be introduced to physicians and community partners as part of a larger effort to build community resilience. Structured interviews also reveal a need for a framework that provides guidance, structure, and support for child health systems and community partners to develop collective goals, shared work plans, and a means for data-sharing to reinforce the components that will contribute to community resilience. ConclusionsKey informant interviews and focus group dialogues revealed a deep understanding of the factors related to toxic stress and ACEs. Respondents endorsed the BCR approach as a means to explore capacity issues, reduce fragmented health care delivery, and facilitate integrated systems across partners in efforts to build community resilience. Current financing models are seen as a potential barrier, because they often do not support restructured roles, partnership development, and the work to sustain upstream efforts to address toxic stress and community resilience.

Themes emerging from State of Child Health: UK and Australia

Some 20 years ago, it was suggested to the relatively newly established Royal College that it might be advisable to develop a regular report on the health of children of...

Watersheds, forests, and childhood health: global relationships and policy opportunities

BackgroundEcosystems are being degraded worldwide, reducing biodiversity and threatening human well-being. Especially in developing countries, rural and poor households often depend closely on natural capital for their livelihoods and health. However, the health consequences of ecosystem declines remain difficult to predict. Here, we report on two multicountry analysis to investigate general relationships between ecosystems and human health for these vulnerable populations. MethodsWe compiled a unique dataset covering about 300 000 children from more than 35 countries, by combining Demographic and Health Surveys (DHS) with additional information about socioeconomic, climate, and environmental factors. We first examined the relationship between watershed conditions and diarrhoeal disease, a major cause of child malnutrition and mortality worldwide. In a second analysis, we then related forest cover more broadly to three health outcomes: diarrhoea, stunting, and anaemia. For both analyses, we used nested mixed-effects logit models to predict the probability of disease based on environmental variables as well as covariates representing climate, sanitation, education, and wealth. FindingsIn the first analysis, we find that more human activity upstream increases the probability of reported diarrhoea (model coefficient 0·10 [standard error (SE) 0·02]), and that higher tree cover upstream reduces it (–0·13 [0·04]). These effects are statistically significant for rural households (human activity: 0·11 [SE 0·03]; tree cover: −0·17 [0·05]), but not urban households (human activity: 0·07 [SE 0·04]; tree cover: −0·07 [0·06]), suggesting shifting dependences from natural to built capital. In the second analysis, we find that increased forest cover reduced the probabilities of all three diseases for the poorest segment of the population, but not for the wealthiest, again indicating differential dependencies on nature. InterpretationThese analyses provide evidence that intact ecosystems are associated with improved child health outcomes, especially for the most vulnerable populations. Under certain conditions, therefore, efforts to protect and restore ecosystems could be considered an important public health investment. FundingUS National Science Foundation National Socio-Environmental Synthesis Center (NSF DBI-1052875); Gordon and Betty Moore Foundation; and Mava Foundation via the Luc Hoffmann Institute at WWF International.

Do systematic reviews on pediatric topics need special methodological considerations?

BackgroundSystematic reviews are key tools to enable decision making by healthcare providers and policymakers. Despite the availability of the evidence based Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA-2009 and PRISMA-P 2015) statements that were developed to improve the transparency and quality of reporting of systematic reviews, uncertainty on how to deal with pediatric-specific methodological challenges of systematic reviews impairs decision-making in child health. In this paper, we identify methodological challenges specific to the design, conduct and reporting of pediatric systematic reviews, and propose a process to address these challenges.DiscussionOne fundamental decision at the outset of a systematic review is whether to focus on a pediatric population only, or to include both adult and pediatric populations. Both from the policy and patient care point of view, the appropriateness of interventions and comparators administered to pre-defined pediatric age subgroup is critical. Decisions need to be based on the biological plausibility of differences in treatment effects across the developmental trajectory in children. Synthesis of evidence from different trials is often impaired by the use of outcomes and measurement instruments that differ between trials and are neither relevant nor validated in the pediatric population. Other issues specific to pediatric systematic reviews include lack of pediatric-sensitive search strategies and inconsistent choices of pediatric age subgroups in meta-analyses. In addition to these methodological issues generic to all pediatric systematic reviews, special considerations are required for reviews of health care interventions’ safety and efficacy in neonatology, global health, comparative effectiveness interventions and individual participant data meta-analyses. To date, there is no standard approach available to overcome this problem. We propose to develop a consensus-based checklist of essential items which researchers should consider when they are planning (PRISMA-PC-Protocol for Children) or reporting (PRISMA-C-reporting for Children) a pediatric systematic review.SummaryAvailable guidelines including PRISMA do not cover the complexity associated with the conduct and reporting of systematic reviews in the pediatric population; they require additional and modified standards for reporting items. Such guidance will facilitate the translation of knowledge from the literature to bedside care and policy, thereby enhancing delivery of care and improving child health outcomes.

The impact of psychological distress during pregnancy on the developing fetus: biological mechanisms and the potential benefits of mindfulness interventions

The in utero environment plays an essential role in shaping future growth and development. Psychological distress during pregnancy has been shown to perturb the delicate physiological milieu of pregnancy, and has been associated with negative repercussions in the offspring, including adverse birth outcomes, long-term defects in cognitive development, behavioral problems during childhood and high baseline levels of stress-related hormones. Fetal epigenetic programming, involving epigenetic processes, may help explain the link between maternal prenatal stress and its negative effects on the child. Given the potential long-term effects of early-life stress on a child's health, it is crucial to minimize maternal distress during pregnancy. A number of recent studies have examined the usefulness of mindfulness-based programs to reduce prenatal psychological stress and improve maternal psychological health, and these are reviewed here. Overall, the findings are promising, but more research is needed with large studies using randomized controlled study designs. It remains unclear whether or not such interventions could also improve child health outcomes, and whether these changes are modulated at the epigenetic level during fetal development. Further studies in this area are needed.

Assessing levels and trends of child health inequality in 88 developing countries: from 2000 to 2014

ABSTRACT Background: Reducing child mortality was one of the Millennium Development Goals. In the current Sustainable Development Goals era, achieving equity is prioritized as a major aim. Objective: This study aims to provide a comprehensive and updated picture of inequalities in child health intervention coverage and child health outcomes by wealth status, as well as their trends between 2000 and 2014. Methods: Using data from Demographic Health Surveys and Multiple Indicator Cluster Surveys, we adopted three measures of inequality, including one absolute inequality indicator and two relative inequality indicators, to estimate the level and trends of inequalities in three child health outcome variables and 17 intervention coverages in 88 developing countries. Results: While improvements in child health outcomes and coverage of interventions have been observed between 2000 and 2014, large inequalities remain. There was a high level of variation between countries’ progress toward reducing child health inequalities, with some countries significantly improving, some deteriorating, and some remaining statistically unchanged. Among child health interventions, the least equitable one was access to improved sanitation (The absolute difference in coverages between the richest quintile and the poorest quintile reached 49.5% [42.7, 56.2]), followed by access to improved water (34.1% [29.5, 38.6]), and skilled birth attendant (SBA) (34.1% [28.8, 39.4]). The most equitable intervention coverage was insecticide-treated bed net for children (1.0% [−3.9, 5.9]), followed by oral rehydration therapy for diarrhea ((8.0% [5.2, 10.8]), and vitamin A supplement (8.4% [5.1, 11.7]). These findings were robust to various inequality measurements. Conclusions: Although child health outcomes and coverage of interventions have improved largely over the study period for almost all wealth quintiles, insufficient progress was made in reducing child health inequalities between the poorest and richest wealth quintiles. Future efforts should focus on reaching the poorest children by increasing investments toward expanding the coverage of interventions in resource-limited settings.

Community health worker interventions are key to optimal infant immunization coverage, evidence from a pretest-posttest experiment in Mwingi, Kenya.

IntroductionImmunization is a powerful and cost-effective health intervention which averts an estimated 2 to 3 million deaths every year. Kenya has a high infant and under five mortality and morbidity rates. Increasing routine child immunization coverage is one way of reducing child morbidity and mortality rates in Kenya. Community Health Workers (CHWs) have emerged as critical human resources for health in developing countries. The Community Strategy (CS) is one of the CHW led interventions promoting Maternal and Child Health (MCH) in Kenya. This study sought to establish the effect of CS on infant vaccination Coverage (IVC) in Mwingi west sub-county; Kenya.MethodsThis was a pretest - posttest experimental study design with 1 pretest and 2 post-test surveys conducted in intervention and control sites. Mwingi west and Mwingi north sub-counties where intervention and control sites respectively. Sample size in each survey was 422 households. Women with a child aged 9-12 months were main respondents.ResultsIntervention site end-term evaluation indicated that; the CS increased IVC by 10.1% (Z =6.0241, P <0.0001), from a suboptimal level of 88.7% at baseline survey to optimal level of 98.8% at end term survey. Infants in intervention site were 2.5 times more likely to receive all recommended immunizations within their first year of life [(crude OR= 2.475, P<0.0001; 95%CI: 1.794-3.414) (adj. OR=2.516, P<0.0001; 95%CI: 1.796-3.5240)].ConclusionCS increased IVC in intervention site to optimal level (98.8%). To improve child health outcomes through immunization coverage, Kenya needs to fast-track nationwide implementation of the CS intervention.

Mindful feeding and child dietary health

ObjectiveThis study examined the relationship between mindful feeding as a novel construct and parent-reported child dietary intake. MethodsParticipants (N=497) were parents of children ages 2.9 to 7.5 recruited through Amazon Mechanical Turk (MTurk). Parents were primarily non-Hispanic white (79%) and female (76%). Simple and hierarchical regression analyses were conducted to examine the associations between parental mindful feeding (i.e., parent mental and emotional presence while feeding a child) and their children's dietary intake. ResultsMindful feeding accounted for 5.1% of the unadjusted variance in child fruit and vegetable intake. Mindful feeding accounted for 4.2% of the unadjusted variance in child added sugar consumption after accounting for relevant covariates. Specifically, higher parental mindful feeding predicted higher fruit and vegetable intake and lower sugar intake among children. ConclusionsMindful feeding was associated with almost all indicators of healthier child diet, indicating great potential for this approach to improve child health. If incorporated into general or health-focused interventions for parents, mindfulness could significantly improve child health outcomes. Further development and validation of the Mindful Feeding Questionnaire is also recommended, as it could become a useful survey tool to assess for this construct.

Disaggregated data to improve child health outcomes.

BackgroundThe District Health Information System was developed in South Africa to collect aggregated routine data from public health facilities. In Amajuba District, KwaZulu-Natal, ward-based data collection has been initiated to facilitate improved responsiveness to community health needs and improve health outcomes and patient satisfaction.AimTo assess the application of the municipal ward-based health data in the decision-making process to improve child health outcomes.SettingThe study was conducted in 25 primary health care service sites in Amajuba.MethodsA cross-sectional mixed methods’ approach was used. The study population comprised operational managers, professional nurses, ward-based outreach team leaders and supervisors. Quantitative data were collected using a semi-structured questionnaire and analysed using descriptive statistics. Qualitative data were collected using focus group discussions and analysed using thematic analysis.ResultsOf the 131 respondents, 83 (67.5%) provided targeted child interventions to a certain or a large extent to improve child health outcomes, but only 74 (57.4%) respondents reported using municipal ward-based health data to a certain or large extent in order to inform their decisions. This discrepancy indicates poor utilisation of local health information for decision-making.ConclusionThe study showed that municipal ward-based health data are not fully utilised for making informed decisions to improve child health outcomes. It is imperative to inculcate a culture of evidence-informed decisions that leads to provision of targeted interventions in order to mitigate the challenge of scarcity of resources and to improve child health outcomes.

U.S. Preventive Services Task Force Approach to Child Cognitive and Behavioral Health.

An important component of routine preventive care for children is the monitoring of growth and development. Although cognitive, affective, and behavioral health problems are commonly encountered in pediatric primary care, there is debate around issues related to early detection of significant problems of this type, including the accuracy of screening and the benefits and harms of early diagnosis and treatment. The U.S. Preventive Services Task Force makes recommendations regarding clinical preventive services for primary care clinicians based on the best available scientific evidence. The Task Force has found important gaps related to the validity of commonly used screening tools and significant gaps related to the evidence regarding early treatment. This review describes the meaning of the grades used by the Task Force, how these grades are determined, and the grades assigned to childhood cognitive, affective, and behavioral health recommendations. The review summarizes common themes in the evidence gaps and the future research necessary to advance the field and improve child health outcomes.

Going online to improve child health outcomes

Going online to improve child health outcomes

Context Matters: A Community-Based Study of Urban Minority Parents’ Views on Child Health

Among children, there are substantial ethno-racial minority disparities across a broad range of health-related behaviors, experiences, and outcomes. Addressing these disparities is important, as childhood and adolescence establish health trajectories that extend throughout life. The current study employed a community-based participatory research approach to gain community insight on child health priorities and to frame an intervention aimed at improving the health of minority children. Eight focus groups were conducted among seventy-five African American parents in a Southeastern city. The current study was guided by an ecological theoretical framework. Although the focus of this investigation was on community identification of child health priorities, participants cited, as root determinants, contextual factors, which included lack of healthy food options, lack of spaces for physical activity, and community violence. These co-occurring factors were related to limited engagement in outdoor activities and physical activity, increased obesity, and poor mental health and coping. Poor parenting was cited as the most substantial barrier to improving child health outcomes, and quality parenting was identified as the most important issue to address for community programs focused on promoting the health and success of children. For improving health outcomes for children in their neighborhoods, establishment of positive social capital and constructive activities were also cited. These results reinforce social determinants of health as influences on child health outcomes and describe how community engagement can address potential solutions through interventions that resonate with program participants.

Health Interventions and Child Health in Sub-Saharan Africa: Assessing the Impact of the Millennium Development Goal

The study investigates the role of health interventions on child health in developing Africa for the period 1990-2013 using a dynamic panel approach. Among others, the study examines the effect of millennium development intervention programme on child health outcomes. Our analysis reveals MDG intervention as extremely pertinent in reducing the incidence of child mortality in Africa. It implies that introduction of MDGs culminates into increasing the rate of child survival in Africa. Similarly, maternal literacy, maternal health and other child protective measures adopted were found to be statistically significant in improving child health outcomes. The proportion of under-five mortality (proxy for child health) responds more strongly and negatively to immunization coverage, exclusive breastfeeding and DPT vaccines. On the other hand, the quality of institution contributively impact under-five mortality in Africa. Finally, there is need to strengthen institutional arrangement, ensure compulsory basic education for women and strengthen the health system to achieve full packages of intervention, curtain the rising incidence of child deaths and attain the MDGs.

Domestic Violence, Intrahousehold Bargaining and Child Health Development in Ghana

I explore a unique exogenous instrument to examine how the intra-familial position of women influence health outcomes of their children using micro data from Ghana. Using the 2SLS-IV estimation technique, I build a model of household bargaining and child health development with perceptions of women regarding wife-beating and marital rape in the existence of domestic violence laws, in Ghana. Even though the initial OLS estimates suggest that women’s participation in decisions regarding purchases of household consumption goods help to improve child health outcomes, the IV estimates reveal that the presence of endogeneity underestimates the impact of women’s bargaining power on child health outcomes. Our choice of instrument is robust to endogeneity, father characteristics and residency robustness checks

Maternal and Child Health in Turkey Through the Health Transformation Program (2003-2008)

Improving maternal and child health outcomes is a major development objective. Targets related to these outcomes were included in the United Nation’s Millennium Development Goals and they continue to galvanize global support through the Sustainable Development Goals (under Goal 3 health targets). Turkey is among the few successful middle-income countries that have significantly reduced the under-5 mortality rate below the MDG 2015 target levels. This study analyses improved demand-side (health insurance, conditional cash transfers) and supply-side inputs (expanded health services) in Turkey’s health system as part of the Health Transition Program (HTP), as well as contextual improvements (such as improved economic well-being and increased maternal educational attainment), to identify how these input factors have advanced health outcomes. The results show that while demand-side measures, such as universal health coverage through extension of health insurance to low-income families (Green Card program), improved health utilisation variables, the main impact of on maternal and child health was through supply side improvements which expanded for all women access to free antenatal and midwifery care, regardless of health insurance status.

Picture of the health status of Aboriginal children living in an urban setting of Sydney.

Objectives The aims of the present study were to: (1) describe the health status and health indicators for urban Aboriginal children (age 0-16 years) in south-east Sydney; and (2) evaluate the quality of routinely collected clinical data and its usefulness in monitoring local progress of health outcomes. Methods Aboriginal maternal and child health routine data, from multiple databases, for individuals accessing maternal and child health services between January 2007 and December 2012 were examined and compared with state and national health indicators. Results Reductions in maternal smoking, premature delivery and low birthweight delivery rates were achieved in some years, but no consistent trends emerged. Paediatric services had increased referrals each year. The most frequent diagnoses were nutritional problems, language delay or disorder and developmental delay or learning difficulties. Twenty per cent of children had a chronic medical condition requiring long-term follow-up. Aboriginal children were more likely to be discharged from hospital against medical advice than non-Aboriginal children. Routinely collected data did not include some information essential to monitor determinants of health and health outcomes. Conclusions Aboriginal children living in this urban setting had high levels of need. Routinely recorded data were suboptimal for monitoring local health status and needed to reflect national and state health indicators. Routinely collected data can identify service gaps and guide service development. What is known about this topic? Despite improvements in some areas, there continue to be significant gaps in maternal and child health outcomes between Aboriginal and non-Aboriginal Australians. These are poorly documented at a local service level. What does this paper add? Intensive, local services offered to Aboriginal women and children can result in rapid service engagement. Health service data routinely collected by local services can be used to demonstrate reductions in antenatal risk factors in pregnant Aboriginal women, even within the short time frame of 6 years. However, improvements in child health outcomes may require longer time frames. In this urban setting, the most frequent diagnoses in Aboriginal children attending the service were nutritional problems, language delay or disorder and developmental delay or learning difficulties. What are the implications for practitioners? Key information regarding determinants of health should be routinely monitored at a local level to understand local rates and health needs in addition to evaluating and quantifying the effectiveness of service delivery or health promotion activities.

Maternal Education and Child Health in India: Role of Pathways of Impact

Studies in the past have found a strong positive association between maternal education and child health. What remains contentious is the nature of this relationship. Firstly, how much of the association is due to maternal education serving as a proxy for socioeconomic status and regional factors? Secondly, how does a higher level of maternal education translate into improved child health outcomes? This paper aims to examine these questions by analysing the relationship between mother’s level of education and child height-for-age, or stunting in India. Using a nationwide family and household survey (NFHS-3, 2005-06), I estimate multivariate regressions to examine how the impact of education varies across model specifications. In particular, I examine the role of three pathways in serving as potential mechanisms through which maternal education has a positive impact on child outcomes. These are (1) Information Processing Effects (2) Maternal Autonomy (3) Use of Community Services. I also use fixed effects estimations to account for village level heterogeneity. The results show that a significant portion of the effect of maternal education can in fact be attributed to socioeconomic variables and community level factors. The analysis gives us insightful findings regarding the differential impacts on child health across various categories of maternal education, the role of the pathways, and how these effects change across specifications. The results have relevant policy implications in the context of improving child health status in India.

Public versus Private Investment in Determining Child Health Outcomes in India: A Quantile Regressions Approach

This paper examines the relationship between access to drinking water, sanitation facilities, and health outcomes for children in India. We use the NFHS 2005-2006 household-level survey data to construct the conditional nutritional distribution for two anthropometric health measures for children between ages six months to two years that capture both short term and longer term health outcomes: the weight-for-height (wasting - short term) and height-forage (stunting - long term) z-scores. Using a quantile regressions approach, we find that public goods such as piped water and access to healthcare facilities are not associated with improving child health outcomes. On the other hand, private investments within the home such as pit latrines and flush toilets do have a strong influence on health outcomes, with the magnitude of the effects being the largest in the middle of the respective conditional nutritional distributions. Further, rural children at the lower end of the nutritional distribution benefit much more than their urban counterparts. We also find that the educational attainment of the mother has a strong association with better health outcomes, both in the short run as well as the long run. Finally, access to well water and boiling drinking water also matter, though their effects depend on whether the underlying health measure is a short term or long term one, and the child's relative position in the conditional nutritional distribution. Over all, our results provide evidence against one size fits all policies, and point towards incentives for private investments in sanitation and mother's education, especially in rural areas and for children in the middle of the conditional nutritional distribution.

Medical legal partnership and health informatics impacting child health: Interprofessional innovations

Dramatic differences in health are closely related to degrees of social and economic disadvantage. Poverty-induced hardships such as food insecurity, utility shut-offs, and substandard housing, all have the potential to negatively impact the health of families. In an effort to better address social determinants of health in pediatric primary health care settings using the Medical Legal Partnership (MLP) model of health care delivery, an interprofessional team of investigators came together to design an innovative process for using computerized clinical decision support to identify health-harming legal and social needs, improve the delivery of appropriate physician counseling, and streamline access to legal and social service professionals when non-medical remedies are required. This article describes the interprofessional nature of the MLP model itself, illustrates the work that was done to craft this innovative health informatics approach to implementing MLP, and demonstrates how pediatricians, social workers and attorneys may work together to improve child health outcomes.

Household wealth, residential status and the incidence of diarrhoea among children under-five years in Ghana

This study examines the impact that the joint effect of household wealth quintile and urban–rural residence has on the incidence of diarrhoea among Ghanaian children. Data for this paper were drawn from the Ghana Multiple Indicator Cluster Survey (MICS) of 2006. Descriptive and logistic regression was applied to analyse data on 3466 children. Rural residents are less likely, albeit insignificant, to report diarrhoea compared with those in urban areas. Significant wealth gradients are manifested in childhood experiences of diarrhoea. However, an interaction of wealth with residence does not show significant disparities. Controlling for other important covariates of childhood, the odds of diarrhoea incidence were significantly higher among: the rural poorer (OR=4.869; 95% CI=0.792, 29.94), the rural middle (OR=7.477; 95% CI=1.300, 42.99), the rural richer (OR=6.162; 95% CI=0.932, 40.74) and the rural richest (OR=6.152; 95% CI=0.458, 82.54). Apart from residential status and wealth quintile, female children (OR=0.441; 95% CI=0.304, 0.640), older children (OR=0.968; 95% CI=0.943, 0.993), having a mother with secondary and higher education (OR=0.313; 95% CI) had lesser odds of experiencing diarrhoea. The findings show that there is a need to apportion interventions intended to improve child health outcomes even beyond residential status and household wealth position.